头颈鳞癌颈部N_0的局限性颈清扫术

目的：头颈部肿瘤颈部Ｎ０的处理有不同意见。本文提供两组病例：一组为１４９例喉癌声门上型;一组为２１９例舌活动部癌。试图从这两组患者治疗结果讨论Ｎ０适宜治疗。方法：我科于１９７６～１９９０年外科或综合治疗声门上型喉癌１４９例;１９６０～１９９３年外科或放射治疗舌活动部鳞癌２１９例。这两类病种均易有颈淋巴结转移,均为Ｔ１～４Ｎ０病例。声门上癌颈部做上颈清扫术;舌癌大部做全颈清扫术。两组原发灶以手术或放射治疗。利用手术标本病理检查及随诊资料进行分析讨论。结果：声门上型喉癌Ｎ０上颈清扫术后,病理无淋巴结转移者１４９例（病理有转移者立即做全颈清扫,不包括在这一组内）,５年观察后有１５例（１０．１％）出现颈转移。和文献报告全颈清扫后复发率可以相比。２１９例舌癌患者１１６例做全颈清扫,病理阳性率为１９．８％（２３／１１６）。３年观察后颈部复发的病例如下：原发与颈部放疗者１７．２％（１０／５８）;颈部无治疗者１６．１％（５／３１）;颈清扫病理阴性者１２．０％（１０／８３）。统计学上无差别。结论：对Ｎ０患者,无需做经典性全颈清扫术。对声门上型患者,上颈清扫（Ⅱ组淋巴结）做为诊断措施可以解决问题,进一步可以考虑肩胛舌骨肌上清扫     

头颈部鳞状上皮细胞癌部N0的处理——声门上型喉癌

对声门上型喉癌颈部无肿大转移淋巴结患者，进行回顾性分析，探讨适宜的处理方案。我院自１９７６年至１９９０年共外科治疗１６２例Ｔ１￣４Ｎ０患者。原发处进行各类学术治疗，颈部做上颈淋巴结切除术。有１３例冰冻病理检查阳性，即做颈清扫术。１４９例病理阴性者观察随诊５年。颈部复发或转移者１５例，颈部失败率为１０．１％。全组５年生存率：Ｔ１Ｎ０为９２．８％，Ｔ２Ｎ０为８６．５％，Ｔ３Ｎ０为６９．７％，Ｔ４Ｎ０为     

声门上型喉癌临床颈淋巴结阴性患者颈清扫区域的选择

目的 探讨声门上型喉癌临床诊断NO(clinical NO,cNO）患者颈淋巴结转移的特点，选择合理的清扫区域。方法 5例声门上型喉癌患者行喉切除术的同时行改良性颈清扫术，将颈清扫的淋巴结标本分区域逐一行病理学检查，确定转移区域或复发的区域。结果 57例（63侧）颈清扫标本共获淋巴结1877枚，平均每侧获29．8枚，有转移的43枚，其中41枚位于Ⅱ、Ⅲ区，占转移例数的95．4％（41／43）。15例（17侧）患者有淋巴结转移，转移率为26．3％（15／57）。其中14例位于Ⅱ、Ⅲ区，占转移例数的93．3％（14／15）。颈部复发3例，复发率为5．3％（3／57），复发部位分别为Ⅱ、Ⅲ、Ⅳ区。5年生存率为80．7％（46／57）。结论 对声门上型喉癌cNO重点行Ⅲ和Ⅲ区颈淋巴结清扫术，Ⅲ区受累时应包括Ⅳ区，Ⅰ、Ⅴ区在无明显转移证据时可避免行颈清扫术。     

声门上型喉癌患者血清癌胚抗原水平与潜在性颈淋巴结转移的关系

血清癌胚抗原 (ＣＥＡ)作为肿瘤标记物 ,多见于结肠癌、乳腺癌等 ,其与喉癌的相关性研究鲜见报道。声门上型喉癌颈淋巴结转移率高 ,尤其对术前颈部触诊未见明显转移灶者 ,颈清扫术的时机选择是提高疗效的关键。本文采用单克隆抗体 放射免疫测定法对 5 7例声门上型喉癌患者进行测定 ,旨在探讨其与淋巴结转移的关系 ,为颈清扫术提供参考指标。1　资料与方法1 .1　临床资料5 7例声门上型喉癌 ,术前颈部均未触及包块 ,术后均经病理证实为鳞癌。其中Ⅰ期 1 5例 ,Ⅱ期1 6例 ,Ⅲ期 1 6例 ,Ⅳ期 1 0例。经病理确诊颈淋巴结转移 (Ｎ+)组 2 8例 ,男 1…     

声门上型喉癌患者两期双侧颈淋巴结清扫术的疗效比较

目的 :总结双侧颈淋巴结清扫术在处理声门上型喉癌颈部淋巴结转移癌中的临床意义。方法 :对76例声门上型喉癌患者在切除原发灶同时 ,将术前诊断双侧颈淋巴结转移的 33例进行同期双侧颈清扫术 (同期清扫组 ) ;一侧颈部淋巴结转移的 43例行一侧颈清扫术 ,随诊中发现对侧转移再行 2期对侧颈清扫术 (分期清扫组 )。结果 :同期清扫组 3年生存率为 81.5 % (2 2 / 2 7) ,5年生存率 6 1.5 % (16 / 2 6 ) ;1例术后当天死于脑压增高。分期清扫组 3年生存率为 6 9.2 % (2 7/ 39) ,5年生存率 2 7.8% (10 / 36 ) ;1例术后当天呼吸道梗阻死亡。结论 :声门上型喉癌双侧颈转移淋巴结同期清扫术 ,比双侧分期清扫术期能明显提高患者的生存率。术中尽可能保留双侧颈内静脉 ,必要时行血管吻合重建颈内静脉 ,能减少术后的并发症。     

声门上型喉癌N_0患者颈淋巴结转移及临床处理

声门上型喉癌在各类型喉癌中最易发生颈淋巴结转移〔1〕。目前对于声门上型喉癌术前已发现颈淋巴结肿大者 (Ｎ+)需行各种类型的颈清扫术已成共识 ;而对手术前未发现颈淋巴结转移者 (Ｎ0 )的处理意见则不一致。本文就近年来有关声门上型喉癌Ｎ0 患者的临床研究资料综述如下。1　Ｎ0 患者颈淋巴结转移的比例近年来许多学者对Ｎ0 患者行同期或 2期颈清扫术后的标本进行连续病理切片 ,发现隐匿淋巴结转移比例为 0～ 6 2 .5 % 〔2 ,3〕,平均在 3 0 %左右。贾深汕 (1 998)曾对术前未经过任何手术、化疗及放疗的声门上型喉癌Ｎ0 患者进行随机分组 ,…     

声门上型喉癌颈部淋巴结转移N1的处理与转归

为探讨声门上型喉癌颈部淋巴结转移更好的处理方法，回顾性分析１９７９年～１９９０年１１１例声门上型喉癌ｃＴ１－４Ｎ１患者病例资料，通过对颈部淋巴结的处理方式与转移或复发部位之间关系的探讨，发现Ｎ１病变对侧颈部淋巴结的潜在性转移有较高比例，其中尤以同侧颈清扫标本阳性的Ｔ３、４病变明显，为３８．６％。单纯手术组对侧颈部淋巴结转移率高于放疗＋手术组，经统计学处理差异有显著性，提示放疗对颈部淋巴结潜在转移有一定的控制作用。     

声门上型喉癌N_0术前放疗的随机对照研究

声门上型喉癌临床Ｎ＿０１００例，随机对照研究术前放疗４０Ｇｙ对控制颈部淋巴结隐匿性转移的作用。放疗加手术（综合治疗组）４６例，单纯手术５４例，随诊３～１２年。综合治疗组颈部复发率为１５％（７／４６），单纯手术２６％（１４／５４），但无统计学意义，提示４０Ｇｙ的剂量可能对颈部转移的控制不够。放疗加手术组Ｔ＿４颈部复发率３３％，比Ｔ＿（１～３）的３．６％明显增高。因此，建议Ｔ＿４声门上型喉癌应常规做一侧传统的根治性颈清扫术（ＲＮＤ），增加术前或术后放疗剂量到５０Ｇｙ。     

声门上型喉癌颈淋巴结隐匿性转移

目的探讨声门上型喉癌隐匿性颈淋巴结转移的特点和规律。方法对１００例声门上型喉癌临床Ｎ０患者和颈廓清标本（１５３侧）进行连续切片,光镜观察。结果隐匿性转移率为３８％,发现转移淋巴结５１个,Ⅰ区１个（２％）,Ⅱ区３７个（７３％）,Ⅲ区１２个（２３％）,Ⅳ区１个（２％）,转移淋巴结的长径０．５～２．６ｃｍ,平均为１．１ｃｍ。５１个淋巴结中癌早期２１个（４１％）,癌长期１８个（３５％）,癌满期７个（１４％）,破膜期５个（１０％）。结论声门上型喉癌颈淋巴结的隐匿性转移率高,早期不易诊断,应积极行选择性颈廓清术。     

声门上型喉癌颈部淋巴结转移N1的处理与转归

为探讨声让上型喉型癌颈部淋巴结转移更好的处理方法，回顾性分析了９１７９年－１９９０年１１１例声门上型喉癌ｃＴ１－４Ｎ１患者病例资料，通过对颈部淋巴结的处理方式与转移或复发部位之间关系的探讨，发现Ｎ１病变对侧颈部淋巴结的潜在性转移有较高比例，其中尤以同侧颈清扫标本阳性的Ｔ３，４病变明显，为３８．６％。     

Upper neck (level II) dissection for N0 neck supraglottic carcinoma

OBJECTIVES: Elective neck dissection for the N0 neck in head and neck surgery is still controversial. This prospective nonrandomized study of N0 supraglottic carcinoma was designed to find an appropriate method of neck management. STUDY DESIGN: Anatomical studies show that the first echelon of lymphatic drainage from the supraglottic larynx is toward the upper jugular nodes (level II). An upper neck dissection (UND) was applied and all the lymph nodes were sent for frozen section. If the subclinical metastasis was found, a modified neck dissection was performed. If the nodes harbored no foci of cancer, the patients were observed after surgery on the supraglottic lesions. METHODS: Patient records of 142 patients with supraglottic laryngeal cancer (T1-4N0M0) were reviewed, with special attention paid to neck recurrences and survival rates. The cases were treated between 1976 and 1990 and all were observed for at least 5 years after the operation or until the time of death. RESULTS: The UND specimens of 142 patients were negative for metastasis. The 5-year survival rate for this group after surgery was 80.8%, according to the life table analysis. Fifteen of the 142 patients (10.6%) had neck recurrences during the period of observation within 5 years. The recurrence rate of this series with limited dissection on the neck was comparable with those reported in the literature after neck dissection, either radical or modified. CONCLUSIONS: There is no need for a comprehensive neck dissection for N0 supraglottic laryngeal cancer. A selective neck dissection such as UND (level II) or a supraomohyoid neck dissection (sparing the submandibular region) of level II and III will serve the purpose of radical neck treatment for the supraglottic cancer.     

CO2激光手术治疗声门上型喉癌

目的 总结CO2激光手术治疗声门上型喉癌的临床治疗效果.方法 回顾性分析1995年2月至2005年6月CO2激光手术治疗的32例声门上型喉癌患者临床资料.32例患者中T1N0M0 20例,T1N1M0 2例,T2N0M0 8例,T2N1M0 2例,全部病例术后随诊3年以上.喉部肿瘤均经口行激光手术,同期行择区性(Ⅱ-Ⅳ区)颈清扫术12例,改良全颈清扫术4例.结果 KaplanMeier法统计5年生存率为90.6%,其中T1病变5年生存率为95.6%,T2病变为78.2%.喉的局部控制率为96.8%;喉局部和颈部区域5年控制率为90.3%,其中T1病变5年局部区域控制率为90.9%,T2病变为89.0%.喉部局部复发2例,1例再治疗行喉水平垂直部分切除术,1例行喉全切除术.颈部区域复发2例,其中1例喉部复发伴颈淋巴转移,再治疗后存活;1例颈部复发,治疗后再次颈部复发并伴肺转移死亡.4例患者出现较轻并发症,保守治疗后好转.除1例患者因局部复发行喉全切除外,其余存活患者喉功能良好.结论 激光治疗早期声门上型喉癌创伤小、疗效可靠,是一种理想的治疗方式.     

声门上型喉癌颈淋巴隐匿性转移及其处理

目的 探讨声门上型喉癌颈淋巴隐匿性转移规律及其处理方法。方法 选择术前未行放疗、化疗的声门上喉鳞状细胞癌，临床N0M0病例，共30例，男19例，女11例；年龄40～72岁，平均54．8岁；按UICC(1997年)标准分期1、28例，1318例，T44例。行主病变侧肩胛舌骨肌上颈清扫术(supraomohyoid neck dissecton，SOHND)，将获得淋巴结逐一行病理组织学检查，观察其转移规律及临床治疗效果。结果 首次颈清扫术30例中有6例颈淋巴结转移癌阳性，在2～3年随访中有3例发生对侧颈淋巴结转移，计有9例颈淋巴转移，隐匿性转移率同侧为20％(6／30)，对侧为10％(3／30)。颈清扫术共获淋巴结527个，平均每侧17．6个。获转移阳性淋巴结10个，其中Ⅱ区9个，Ⅲ区1个，Ⅰ区无癌转移。喉及主病变侧颈部均无复发，2年无瘤生存率86．7％(26／30)。结论 声门上型喉癌颈淋巴结隐匿性转移率达30％，采用Ⅱ、Ⅲ区的择区性颈清扫术处理其颈淋巴结(Ⅰ区可不必作为常规清扫区域)是切实可行的。     

Effectiveness and pitfalls of elective neck dissection in N0 laryngeal cancer

The aim of the study was to evaluate the efficacy and potential pitfalls of selective neck dissection of levels II-IV in controlling occult neck disease in clinically negative neck (cN0) of patients with laryngeal squamous cell carcinoma. Charts of 96 consecutive cN0 laryngeal cancer patients undergoing 122 neck dissections at the University of Florence from January 2000 to December 2004 were reviewed. N0 neck was defined with contrast enhanced computed tomography scan. Occult neck disease rate was 12.5%, involvement per level was: 47.6% at level II, 38.1% at level III, 9.5% at level IV. Six patients developed neck recurrence (6.25%) after selective neck dissection of levels II-IV within the first two years after treatment. In conclusion, selective neck dissection of levels II-IV is effective in N0 laryngeal squamous cell carcinoma; posterior limits of surgical resection are missing therefore if post-operative radiation is required, the field should be extended beyond the dissected levels. The low incidence of occult neck disease indicates the need to refine treatment strategy, restricting elective neck dissection only to supraglottic T2 with epilaryngeal involvement, supraglottic T3-4 and glottic T4 tumours, and considering a "wait and see" protocol implemented with imaging techniques and cytological assessments for other lesions.     

Occult metastases from T1–T2 supraglottic carcinoma: role of primary tumor localization

The present study was undertaken to evaluate the role of localization on the rate of occult metastasis in early stage supraglottic laryngeal carcinoma. We selected carefully 32 T1–2 clinically N0 patients without epilarynx involvement and 39 T1–2 clinically N0 patients with epilarynx involvement from among patients with supraglottic laryngeal carcinoma. All patients underwent simultaneous unilateral or bilateral neck dissection with laryngeal surgery. The rate of the occult metastases was 3.1% in patients without epilarynx involvement, whereas it was 20.5% in patients with epilarynx involvement. Within the supraglottic larynx, two subregions can be distinguished: the epilarynx and the lower supraglottis. Our results suggest the possibility of omitting elective neck treatment in T1–2N0 supraglottic laryngeal carcinoma without epilarynx involvement. Observation under strict follow-up may be an option to routine neck treatment in T1–2N0 supraglottic laryngeal carcinoma without epilarynx involvement.     

The role of supraomohyoid neck dissection at the time of supraglottic laryngectomy

Uncontrolled cervical metastasis is the most common source of failure in the surgical treatment of supraglottic carcinoma. This study was designed to determine the value of supraomohyoid neck dissection in patients undergoing supraglottic laryngectomy. The rationale for considering the role of supraomohyoid neck dissection is that such a dissection encompasses the subdigastric and midjugular nodes which are the first echelon of lymphatic drainage of the supraglottic larynx. Thirty-eight patients with a diagnosis of epidermoid carcinoma of the supraglottis were treated by subtotal supraglottic laryngectomy (SSL). Ten patients underwent SSL with no neck dissection, 16 patients underwent SSL with supraomohyoid neck dissection (SOHD)--9 unilateral and 7 bilateral, and 12 patients underwent SSL with radical neck dissection (RND). The 3 groups had comparable T classifications. All of the SSL and SSL with SOHD patients were classified as N0. Of the 12 patients treated with SSL and RND, 4 were classified as N0, 4 as N1, 3 as N2, and 1 as N3. The patients were studied to determine the incidence and pattern of subsequent neck disease, survival, complications, and length of hospitalization. The data indicates that supraomohyoid neck dissection offers little benefit as an adjunct to supraglottic laryngectomy.     

声门上癌术后颈淋巴结的转移与再发

探讨选择性颈廓清术在声门上癌手术治疗中的作用。方法总结１９８１－１９９３年治疗的５８２例声门上癌术后颈淋巴结转移及廓清侧转移淋巴结再发情况。结果Ｔ３、Ｔ４病例３９２例,而Ｔ３Ｎ＋、Ｔ４Ｎ＋１４７例。     

Selective neck dissection (IIA, III): a rational replacement for complete functional neck dissection in patients with N0 supraglottic and glottic squamous carcinoma

INTRODUCTION: The purpose of this paper is to determine the optimal elective treatment of the neck for patients with supraglottic and glottic squamous carcinoma. During the past century, various types of necks dissection have been employed including conventional and modified radical neck dissection (MRND), selective neck dissection (SND) and various modifications of SND. MATERIALS AND METHODS: A number of studies were reviewed to compare the results of MRND and SND in regional recurrence and survival of patients with supraglottic and glottic cancers, as well as the distribution of lymph node metastases in these tumors. RESULTS: Data from seven prospective, multi-institutional, pathologic, and molecular analyses of neck dissection specimens, obtained from 272 patients with laryngeal squamous carcinoma and clinically negative necks, revealed only four patients (1.4%) with positive lymph nodes at sublevel IIB. Data was also collected from three prospective, multi-institutional, pathologic and molecular studies of neck dissection specimens which include 175 patients with laryngeal squamous carcinoma (only 2 with subglottic cancer) and clinically negative necks. Only six patients (3.4%) had positive nodes at level IV. CONCLUSIONS: SND of sublevel IIA and level III appears to be adequate for elective surgical treatment of the neck in supraglottic and glottic squamous carcinoma. Dissection of level IV lymph nodes may not be justified for elective neck dissection of stage N0 supraglottic and glottic squamous carcinoma. Bilateral neck dissection in cases of supraglottic cancer may be necessary only in patients with centrally or bilaterally located tumors.     

Results of treatment of 584 laryngeal cancers at the Ear-Nose-Throat Clinic of Marburg University

The results in the management of 460 vocal cord carcinomas and 124 supraglottic carcinomas are reported. Of the vocal cord carcinomas, 63.3% were diagnosed in the early Tis and T1 stage. Seventy-six tumors were resected endoscopically, 128 by laryngofissure and chordectomy. Not one of these patients has lost his life, larynx or voice. In bilateral tumors of the T1b category, 2 patients developed local recurrences and lost their larynx. Sixty-two carcinomas of the Tis, T1a and T1b categories were irradiated primarily. Two of these patients died and 14 underwent laryngectomy for local recurrence. In T2 carcinomas a 5-year cure rate of 87.5% was achieved by vertical partial resection. The 5-year cure rate after laryngectomy or laryngectomy with neck dissection for T2N0 and T2N+ carcinoma was 86.2% and 75.0% respectively. Most treatment failures were due to late metastases which could not be controlled. In T3 carcinomas with a 5-year cure rate of 71.4% (N0) and 70.0% (N+) respectively, treatment failures were also mainly seen in patients with N0 necks where we did not carry out a prophylactic neck dissection. Five-year survival rates for primary surgery in supraglottic T1-T4 carcinomas were 100%, 82.4%, 84% and 58.3%. The widely hel opinion that laryngeal carcinoma should only be subjected to surgery for irradiation failure can no longer be sustained. More patients lose their larynx or their life after irradiation of small carcinomas than after primary surgery. Furthermore, too many patients have to undergo two major cancer treatments (irradiation and salvage surgery). In larger carcinomas radiotherapy produces a lower survival rate and too many patients require two stressful cancer therapies. The number of retained larynges is not substantially higher than with primary surgery. Primary irradiation for selected cases should be part of every therapy concept that aims at an adequate and individual treatment of every patient.     

Oncological and functional outcome of conservative surgery for primary supraglottic cancer

The aim of this study was to verify the oncological and functional outcome of conservative surgical treatment of primary supraglottic squamous cell carcinoma (SGSCC) and related neck disease in order to verify the effectiveness of supraglottic laryngectomy (SL) and the validity of an “observation” policy in the control of clinically negative (N0) necks. Of a total of 252 consecutive patients affected by primary SGSCC seen between 1975 and 1990 at the Department of Otolaryngology of the University of Perugia (1975–1987) and the Catholic University of the Sacred Heart of Rome (1988–1990), a subset of 132 patients treated with classical SL was evaluated after presenting sufficient clinicopathological data and a follow-up period of at least 5 years. Tumors were staged according to the 1992 UICC TNM classification and grouped into stages I-II (n = 94) and III-IV (n = 38). Comprehensive neck dissections were performed only in the clinically positive (N+) necks (25/132 cases), while in the clinically N0 ones (107/132 cases) an “observation” policy under strict follow-up conditions was adopted. After primary surgery, the 5-year relapse-free survival (RFS) was 74%. The RFS was 80% for T1-2 disease and 65% for T3. The RFS was 80% for stages I-II tumors and 71% for stages III-IV. The actual 5-year overall survival (OS) was 89% for T1-T2 tumors and 67% for T3 disease or 93% for stages I-II and 69% for stages III-IV. The OS was 89% for N0 neck and 73% for N+. The 5-year-metastasis-free survival (MFS) was 83% for N0 patients, 74% for N+, 84% for T1-T2 N0, 71% for T1-T2 N+, 81% for T3 N0 and 68% for T3 N+. In all, SL was found to be highly effective in the management of primary SGSCC. In the presence of clinically N0 neck “observation” under strict follow-up with therapeutic comprehensive neck dissection for delayed nodal recurrence, SL was suitable for controlling the neck cancer, as well as for salvaging recurrent disease. Bilateral elective, selective or functional neck dissection in every instance of supraglottic cancer was best performed only in those SGSCC patients who were more likely to have occult nodal disease on the basis of biological factors and imaging data. Received: 26 September 1998 / Accepted: 22 February 1999